Three Rivers Healthcare Center

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff documented medication administration accurately in the electronic medical record. This affected one (Resident #99) of five residents reviewed for unnecessary medications. The facility census was 111 residents. Findings include: Review of the medical record of Resident #99 revealed an admission date of 05/10/24 with diagnoses including acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, chronic atrial fibrillation, chronic obstructive pulmonary disease, hypertension (HTN), and heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #99 dated 12/02/24 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of physician's orders for Resident #99 revealed an order dated 12/14/24 for metoprolol tartrate 25 mg give one half tablet by mouth two times per day for HTN and an order dated 01/22/25 to increase the metoprolol tartrate to 25 mg one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and the resident interview, the facility failed to maintain an adequate supply of food during tray service and failed to follow the facility menu. This affected four (Residents #12, #18, #19, and #20) of four residents observed for meal service. The facility census was 115 residents. Findings include: Review of the medical record for Resident #12 revealed an admission date of 05/10/24 with diagnoses including alcohol dependence, respiratory failure, depression, psychoactive substance abuse, anxiety, chronic pain, and insomnia. Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 09/01/24 revealed the resident had no cognitive deficits and required supervision with activities of daily living (ADLs). Review of the medical record for Resident #18 revealed an admission date of 02/14/24 with diagnoses including diabetes, heart failure, epilepsy, colon cancer, and sleep apnea. Review of the MDS for Resident #18 dated 10/30/24 revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Review of medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff maintained proper infection control practices during tracheostomy care. This affected one (Resident #17) of three residents reviewed for tracheostomy care. The facility census was 111 residents. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/29/24 with diagnoses including centrilobular emphysema, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 08/03/24 revealed the resident had intact cognition and required setup assistance with activities of daily living (ADLs.) Observation on 09/24/24 at 11:42 A.M. of tracheostomy care for Resident #17 per Licensed Practical Nurse (LPN) #21 revealed the nurse broke the sterile field when she touched the sterile gauze with her clean gloves instead of sterile gloves. LPN #21 picked up the gauze and placed it in the cleaning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the facility menu, observation, staff interview, resident interview, and review of the facility recipes, the facility failed to serve palatable and appetizing food to the residents. This had the potential to affect all residents residing in the facility with the exception of two facility identified residents (#51, #111) who had orders to receive nothing by mouth. The facility census was 117 residents. Findings include: Review of the facility menu for 08/05/24 revealed the lunch entrée was Dijon pork loin. Observation on 08/05/24 at 11:50 A.M. revealed [NAME] #126 removed a tray of pork loin from the oven that had been cooked in its own juices. On the tray line there was a container of a thick yellow substance which [NAME] #126 identified as gravy. During the tray line service [NAME] #216 used a small scoop to ladle gravy over the top of each serving of pork loin. Observation of a test tray on 08/05/24 at 1:30 P.M. revealed the tray included peas, cabbage, oven roasted potatoes and pork loin with approximately one quarter inch of a thick yellow substance on top of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff provided visual privacy while providing incontinence care to residents. This affected one (Resident #37) of two residents observed for incontinence care. The facility census was 117 residents. Findings include: Review of the medical record for Resident #37 revealed an admission date of 12/22/22 with diagnoses including paraplegia, fusion of the spine, depression, and history of fall from ladder. Review of the Minimum Data Set (MDS) assessment for Resident #37 dated 07/08/24 revealed the resident had no cognitive deficits and required extensive assistance with activities of daily living. Observation of incontinence care for Resident #37 on 08/12/24 from 12:09 P.M. to 12:18 P.M. per two State Tested Nursing Assistants (STNAs #251 and #252) revealed the aides provided incontinence care to the resident and did not draw the blinds to provide visual privacy for the resident. Two residents passed by Resident #37's window and were able to visualize the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure staff discarded expired medication. This affected one (Residents #04) of two facility-identified residents with orders for multivitamins with minerals. The facility census was 117 residents. Findings include: Review of the medical record for Resident #04 revealed an admission date of 12/19/23 with diagnoses including emphysema, diabetes, anxiety, depression, schizoaffective disorder, and insomnia. Review of physician's orders for Resident #04 revealed an order dated 12/20/23 to administer a multivitamin with minerals tablet once daily in the morning. Review of the Minimum Data Set (MDS) assessment for Resident #04 dated 07/03/24 revealed the resident had no cognitive deficits and required supervision for activities of daily living (ADLs). Observation on 08/12/24 at 8:23 A.M. of medication administration for Resident #04 per Licensed Practical Nurse (LPN) #100 revealed the multivitamin with minerals was not available. During administration Central Supply…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview and policy review, the facility failed to ensure personal hygiene was provided for residents. This affected three (Residents #72, #79, and #102) of three residents reviewed for personal hygiene. The census was 117. Findings include: 1. Review of the care plan for Resident #72, dated 10/28/23, revealed he had activities of daily living (ADL) deficits and required assistance with ADL. During observation Observations on 06/10/24 at 11:36 A.M., 06/11/24 at 9:00 A.M. and on 06/12/24 at 2:30 P.M. revealed Resident #72 had jagged nails that came over his fingers and had a yellow brownish substance under his nails. During interview on on 06/12/24 at 2:30 P.M., Licensed Practical Nurse (LPN) #237 confirmed Resident #72's nails were long, jagged, and had a yellowish brownish substance under them. 2. During an observation on 06/12/24 at 2:28 P.M., Resident #89 had long, jagged nails that had a yellowish, brownish substance under the nails. During an interview on 06/12/24 at 2:30 P.M., LPN #237 confirmed Resident #89's nails were long jagged and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide the food portions and liquids as planned by a Registered Dietitian. This affected nine (Residents #7, #11, #39, #50, #57, #72, #81, #89 and #98) residents. The facility total census was 117. Findings include: Record reviews of Residents #7, #11, #39, #50, #57, #81, #89 and #98 revealed a physician order for puree diet. Review of the breakfast spreadsheet reviewed the puree meal was to be served of six ounces of puree oatmeal, two ounces of puree sausage, and two ounces of puree bread. During an observation on 06/13/24 at 8:22 A.M., [NAME] #139 served four ounces of puree oatmeal, four ounces of puree sausage and three ounces of puree bread. During an interview on 06/13/24 at 11:27 A.M., [NAME] #139 verified she had not followed the spread sheet for puree potions. She verified she had served too little portions of the oatmeal and too much of the bread and sausage. [NAME] #139 stated she does not always follow the spreadsheet, which could affect residents on specialty ordered diets. 2. Review of care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview and policy review, the facility failed to prepared fortified foods according to the recipe for increased nutritional value . This affected six (Residents #19, # 46, #47, #50, #79 and #89) of six residents ordered a fortified meal. The census was 117. Findings include: Review of the fortified oatmeal recipe included oatmeal, whole milk, powder milk, sugar, and margarine. During an interview on 06/13/24 at 7:44 A.M., [NAME] #139 stated she prepares fortified oatmeal with powdered milk and butter to make it fortified. [NAME] #139 stated she does not use a recipe to know how to prepare fortified foods, including oatmeal, because she has worked at the facility so long. She stated she could not decipher the recipe because it was made for 100 portions, and she only had six residents with fortified orders. Review of facility policy titled Fortified Food Program, undated and Food Quality and Palatability dated 2023, revealed the facility will prepare food to conserve nutritive value and follow the fortified food recipes as a therapeutic intervention. This…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review, the facility failed to ensure thickened liquids were served as ordered. This affected four (Residents #72, #79, #89 and #98) of four residents reviewed for thickened liquid diets. The census was 117. Findings include: 1. Review of care plan for Resident #72 dated 12/06/23 revealed he was at risk for nutrition and hydration status. Review of physician orders dated 06/03/24 for Resident #72 revealed the resident's diet was dysphagia mechanical texture, and honey thickened liquids. During an observation on 06/12/24 at 9:00 A.M., Resident #72 was served orange juice that was not honey consistency. During an interview on 06/12/24 at 9:20 A.M., Dietician #264 confirmed the meal ticket said honey thickened liquids and the orange juice on the tray was not thickened. Review of facility policy titled, Food Quality dated, 2023, revealed the facility will serve food to meet the resident's needs. 2. Record review of Specified Resident, (SR) #89 revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview and policy review, the facility failed to ensure staff changed gloves , performed hand hygiene and wore the proper personal protective equipment. This affected five (Residents #7, #10, #102, #53 and #38) residents. The census was 117. Findings include: 1. During an observation on 06/10/24 at 1:07 P.M., State Tested Nursing Aide (STNA) #206 checked Resident #7 for incontinence while wearing gloves. She left the resident's room with her gloves on. She went down the hallway, removed her gloves and disappeared out of view. During an interview on 06/10/24 at 1:15 P.M., STNA #206 stated she doesn't remove her gloves in the room after caring for a resident and will go down the hall remove the gloves and wash her hands down at a sink in the hall. She confirmed she didn't know the process, but should have removed her gloves and washed her hands before leaving the resident's room. 2. During an observation on 06/11/24 at 9:15 A.M. Registered Nurse (RN) #262 donned gloves to prepare medications for Resident #10. She removed medications from the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure the Power of Attorney (POA) was contacted when a resident experienced a change of condition. This affected one (Resident #72) of three residents reviewed for notification of a change in condition. The census was 117. Findings included: Review of the medical record revealed Resident #72 was admitted on [DATE]. Medical diagnoses included non-traumatic chronic subdural hemorrhage, hypertension, peripheral vascular disease, renal insufficiency, cerebrovascular accident (CVA), malignant neoplasm of prostate, seizure disorder, and non-Alzheimer's dementia. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was severely cognitively impaired. His functional status was substantial/maximal assistance for eating, dependent for toileting, bed mobility, and transfers. He was always incontinent for bowels and bladder. Review of the progress notes documented on 04/25/24 Resident #72 slept all day, refused his food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation interview and policy review, the facility failed to ensure privacy was provided. This affected one (Resident #7) of one resident reviewed for privacy. The census was 117. Findings included: Medical record review for Resident #7 revealed an admission date of 10/27/23. His medical diagnoses included peripheral vascular disease, diabetes, and dementia. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was moderately cognitively impaired. He required maximum assistance for toileting and bed mobility. During an observation on 06/10/24 at 1:07 P.M., Resident #7's door was open with a full view from the hall. Resident #7 in bed with the blanket and sheets off the resident. The curtain was not pulled and Resident #7's roommate was sitting on his side of the room. State Tested Nursing Aide (STNA) #206 was asking the resident if he had soiled his brief and was feeling the brief to check for wetness. During an interview on 06/10/24 at 1:15 P.M.,STNA #206…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure a homelike environment was maintained. This affected two (Residents #2 and #86) of three residents reviewed for homelike environment. The census was 117. Findings include: 1. During an interview on 06/10/24 at 11:19 A.M., Resident #2 stated housekeeping hasn't come into clean the bathroom yet. He stated the blood was coming from his roommate's urine. During an observation on 06/10/24 at 11:19 A.M., Residetn #2's bathroom had bloody urine in the toilet and drips of blood down the side of the toilet going down to the floor. There was a strong smell of urine. At 2:11 P.M. housekeeper went into the bathroom and removed her gloves, dropping one on the floor. The housekeeper didn't pick up the glove and didn't clean the blood from the toilet. There were still the blood and strong smells of urine in the bathroom. During an observation at 3:39 P.M., there was still bloody urine in the toilet and running down the side of the toilet to the floor and the glove was on the floor. There was a strong smell of urine in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview and policy review, the facility failed to ensure a wound was cleaned properly. This affected one (Resident #102) of three residents reviewed for pressure ulcers. The facility identified nine residents with pressure ulcers. The census was 117. Findings include: Medical record review for Resident #102 revealed an admission date of 05/19/23. His medical diagnoses included neurogenic bladder, paraplegic, and depression. Review of care plan for Resident #102, dated 11/07/23, revealed the resident had altered skin integrity related to spinal fusion and has a stage pressure ulcer to the sacrum. Intervention was to provide peri-care as needed to avoid skin breakdown due to incontinence. Review of physician orders dated 02/29/24 for Resident #102 were to cleanse the wound to the sacrum with wound cleanser or saline. Apply silver alginate inside the wound and secure with super absorbent foam followed by a ABD pad and to use Zinc Oxide on the skin around the wound to secure the ABD pads. During an observation on 06/12/24 at 10:19 A.M., Registered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of self-reported incidents, review of pharmacy documents, review of written statements, and policy review, the facility failed to report an allegation of misappropriation to the State Survey Agency. This affected one (#100) of two residents reviewed for misappropriation. The facility census was 95. Findings include: Record review of Resident #100 revealed the resident was admitted to the facility on [DATE] and expired at the facility on [DATE]. The resident was receiving hospice services. Diagnoses for Resident #100 include diabetes, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had moderately impaired cognition and required extensive assistant of two staff for activities of daily living. Review of physician orders revealed Resident #100 was ordered the antianxiety medication Ativan every four hours as needed starting on [DATE]. Review of Resident #100's nursing progress note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of self-reported incidents, review of pharmacy documents, review of written statements, and policy review, the facility failed to thoroughly investigate an allegation of misappropriation. This affected one (#100) of two residents reviewed for misappropriation. The facility census was 95. Findings include: Record review of Resident #100 revealed the resident was admitted to the facility on [DATE] and expired at the facility on [DATE]. The resident was receiving hospice services. Diagnoses for Resident #100 include diabetes, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had moderately impaired cognition and required extensive assistant of two staff for activities of daily living. Review of physician orders revealed Resident #100 was ordered the antianxiety medication Ativan every four hours as needed starting on [DATE]. Review of Resident #100's nursing progress note dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, review of facility policy, and review of online resources from the Centers for Disease Control (CDC), the facility failed to ensure the staff practiced proper hand hygiene during wound care. This affected one (#14) of the three residents reviewed for wound care. The facility census was 103. Findings include: Review of the medical record for Resident #14 revealed the resident was admitted on [DATE]. Diagnoses included multiple sclerosis (MS), depression, anemia, anxiety, and diabetes mellitus. Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE] for Resident #14, revealed the resident had no cognitive deficits and required extensive assistance with activities of daily living (ADLs). Observation of wound care/dressing change on 11/21/23 at 9:06 A.M. for Resident #14 and being completed by Wound Nurse Practitioner (NP) #51 and Registered Nurse (RN) #66, revealed NP #51 used alcohol-based hand rub (ABHR) and donned gloves.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and review of a facility policy, the facility failed to obtain timely re-weights for residents who experienced a five pound or greater weight loss from the previous weight per the facility policy. This affected five (#22, #23, #27, #54, and #58) of five residents reviewed for weight loss. The facility census was 96. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 11/16/17 with diagnoses including diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), dementia without behavioral disturbance, and depression. Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 07/08/23 revealed the resident was cognitively impaired and required supervision with eating. Review of the weight record for Resident #22 revealed resident's monthly weight on 08/01/23 was 134.0 pounds (lbs.) and on 09/13/23 was 121.4 lbs. Review of the medical record for Resident #22 completed on 09/19/23 revealed there was no re-weight recorded for the resident. Interview on 09/19/23 at 11:26 A.M. with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of resident trust accounts, resident interview, and staff interview, the facility failed to ensure residents had access to their funds in in a timely manner. This affected three (#7, #23, and #50) of three residents reviewed for resident funds access. The facility census was 96. Findings include: Review of facility list of residents with resident trust accounts at the facility provided on 09/18/23 revealed Resident #7, Resident #23, and Resident #50 had resident trust accounts with the facility. Interview on 09/18/23 at 11:00 A.M., with Receptionist #505 confirmed resident banking hours were 8:30 A.M. to 4:30 P.M. on Monday through Friday, and residents came to the front desk if they wanted to withdraw cash from their resident trust account. Receptionist #505 confirmed there was only one other person in the facility who was able to provide banking assistance to residents and that staff member was Community Wide Liaison (CWL) #640. Receptionist #505 confirmed the residents did not have access to their funds in the resident trust account on the weekend. Interviews on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents had the right to access a telephone where calls could not be overheard. This affected three (#89, #92, and #99) of three residents reviewed for resident rights. The facility census was 96. Findings include: 1. Review of the medical record for Resident #99 revealed an admission date of 11/11/22 with diagnoses including contusion and laceration of the cerebrum, vascular dementia with agitation, psychosis, anxiety disorder, hypertension, ischemic heart disease, and malignant neoplasm of the bladder. Review of the Minimum Data Set (MDS) assessment for Resident #99 dated 07/04/23 revealed the resident was cognitively impaired and required supervision with activities of daily living (ADLs). Interview on 09/18/23 at 9:05 A.M., with Licensed Practical Nurse (LPN) #415 confirmed the secured unit did not have a private location for the residents to make phone calls. LPN #415 confirmed if residents wanted to make or receive a call, they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observation, staff interview, and review of a facility policy, the facility failed to store medications in an appropriate manner. This affected two (#87 and #93) of four residents observed for medication administration. The facility census was 96. Findings include: 1. Review of the medical record for Resident #93 revealed an admission date of 01/24/22 with diagnoses including hemiplegia and hemiparesis, chronic obstructive pulmonary disease (COPD), gout, and schizophrenia. Review of the Minimum Data Set (MDS) assessment for Resident #93 dated 06/14/23 revealed the resident was cognitively impaired and required extensive assistance with one to two staff with activities of daily living (ADLs). Review of the September 2023 monthly physician orders for Resident #93 revealed orders dated 05/13/22 for the antianxiety medication Klonopin 0.5 milligrams (mg) three times per day by mouth and nerve pain medication Lyrica 50 mg twice a day by mouth. Observation on 09/18/23 at 8:40 A.M. revealed there was an unlabeled plastic cup in the top drawer of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, review of the facility's policy, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure a resident exhibiting a potential COVID-19 symptom was tested timely, failed to ensure proper Personal Protective Equipment (PPE) was worn when staff sorted potentially infectious dirty laundry, and failed to ensure the infection control log had the recorded information necessary to analyze and control infections. This affected one resident (#13) and had the potential to affect all 94 residents residing in the facility. Findings include: 1. Review of the medical record of Resident #13 revealed an admission date of 05/10/21. Diagnoses included chronic obstructive pulmonary disease and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had impaired cognition. Review of the progress notes dated 05/09/22 to 05/12/22 revealed no evidence of a COVID test being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy, and staff interview, the facility failed to complete weekly skin assessments and weekly weights as ordered by the physician. This affected four (#13, #30, #39, and #290) of six residents reviewed for physician orders. The facility census was 94. Findings include: 1. Review of the medical record of Resident #13 revealed an admission date of 05/10/21. Diagnoses included chronic obstructive pulmonary disease, protein-calorie malnutrition, adult failure to thrive, dysphagia, and hyperlipidemia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #13 had impaired cognition. The resident did not exhibit any behaviors during the assessment period. Review of Resident #13's physician orders dated 09/15/21 revealed orders for a weekly weight every Wednesday on day shift and on 03/21/22, an order to complete a weekly skin assessment every Saturday on day shift. Review of the weekly skin assessments for Resident #13 revealed skin assessments were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy review, the facility failed to ensure opened medication bottles were properly labeled and medications were not kept beyond their expiration date. This affected three of six medication carts and two of three medication rooms. The facility identified all residents received assistance with medication administration. The facility census was 94. Findings include: 1. Observation on 05/11/22 at 2:29 P.M. revealed Elm-One medication cart had an unlabeled, uncovered plastic drinking cup half filled with an orange syrup. Interview on 05/11/22 at 2:30 P.M. with Licensed Practical Nurse (LPN) #120 identified the substance in the plastic as prosource and stated there was only one bottle in the entire building. LPN #120 stated she had one resident on the unit who took it twice daily and she was saving that for the evening dose. LPN #120 stated she retrieved the syrup from another medication cart and placed it in the cart unlabeled this morning during medication pass. 2. Observation on 05/11/22 at 4:31 P.M. revealed Elm-One medication cart had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure food was properly stored in the refrigerator and maintain a sanitary refrigerator and freezer on the Elm unit. This had the potential to affect 30 of 32 residents residing on the Elm unit who received food from the kitchen. The facility identified two residents (#17 and #290) on the elm unit, who did not receive food from the nourishment refrigerators or kitchen. The facility census was 94. Findings include: Observation and interview on 05/11/22 at 6:10 P.M. of the resident's refrigerator on the Elm unit with Personal Care Assistant (PCA) #21 revealed the refrigerator had an unlabeled and undated quart-sized ziplock bag-containing, what appeared to be, cheese, which was moldy. There were two boxes of pizza, each wrapped in a clear garbage bag, stacked on top of each other and not labeled or dated. The pizza in the bag on top contained an unidentifiable brown sticky substance on the outside of the bag. The floor of the refrigerator contained two spots, approximately an inch in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and resident and staff interviews, the facility failed to ensure residents were served meals in a dignified manner. This affected three residents (#43, #292, and #392) residents observed in the dining room. The facility census was 94. Findings include: 1. Observation on 05/09/22 at 12:40 P.M. revealed Nurse Practitioner (NP) #500 was seated at a table in the dining room, eating a bag of microwave popcorn, talking on the phone, and working on her computer. Resident #292 was observed sitting at the table next to that of NP #500, facing NP #500, and watching her eat in the resident dining room. Interview on 05/09/22 at 12:41 P.M. with Resident #292 revealed Resident #292 asked the surveyor where her lunch was. Interview on 05/09/22 at 12:44 P.M. with Registered Dietitian (RD) #82 verified NP #500 was seated at a table facing Resident #292, eating and talking on the phone, while Resident #292 was waiting for her lunch to arrive. RD #82 further confirmed NP #500's actions were not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to ensure advanced directives were correctly documented in the resident's medical record. This affected two (Residents #5 and #28) of two residents reviewed for advanced directives. The facility census was 94. Findings included: 1. Review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, chronic obstructive pulmonary disease with exacerbation, morbid obesity due to excess calories, and acute respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) assessment completed on [DATE] revealed Resident #5 was cognitively intact. Review of the electronic medical record revealed under the profile section, Resident #5's code status was a CPR (cardiopulmonary resuscitation)/Full Code. Review of the physician's orders revealed Resident #5's code status was CPR/Full Code. Review of Resident #5's hard medical record revealed a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to timely provide a resident with an explanation of services terminated and provide information to the residents so they can decided if they wish to continue receiving the skilled services that may not be paid for Medicare and assume financial responsibility. This affected three (Residents #14, #26 and #291) of three residents reviewed for benefit changes. The facility census was 94. Findings include: 1. Record review for Resident #26 revealed the resident was admitted to the facility on [DATE]. Diagnoses included left tibia fracture and chronic obstructive pulmonary disease. Review of the MDS assessment dated [DATE] revealed Resident #26 had impaired cognition. Review of the Notice of Medicare Non-Coverage, (NOMNC) for Resident #26 revealed Medicare Part A coverage was to end on 02/04/22. Resident #26 signed the receipt of the notification on 02/03/22. Interview on 05/12/22 at 12:20 P.M. with the Administrator verified Resident #26 had not received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility's Self-Reported Incident (SRIs), staff interview, and policy review, the facility failed to implement their abuse policy and ensure allegations of resident abuse were reported to the Director of Nursing, Administrator, and State Survey Agency. This affected one (Resident #51) of one resident reviewed for abuse. The facility census was 94. Findings include: Review of the medical record for Resident #51 revealed an admission date of 11/03/16. Diagnoses included Parkinson's disease, psychotic disorder with hallucinations, dementia without behavioral disturbance, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had a severe cognitive impairment. The resident exhibited fluctuating disorganized thinking during the assessment period. Review of a progress note dated 04/21/22 revealed Resident #51 reported to the counselor that a male hit him in the face. The nurse on the unit was notified. Resident #51 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to complete a new pre-admission screening and resident review (PASARR) when a resident received a new diagnosis of schizophrenia. This affected one (Resident #30) of three residents reviewed for PASARR. The facility census was 94. Findings include: Review of the medical record of Resident #30 revealed an admission date of 01/24/22. Diagnoses included depression, dementia with behavioral disturbance, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30's cognitive status was not assessed. Resident #30 did not exhibit any behaviors during the assessment period. Review of the medical record of Resident #30 revealed the diagnosis of Schizophrenia was added on 02/15/22. Review of the PASARR dated 02/03/22 revealed section E: Indications of Serious Mental Illness, was checked no for the presence of mental disorders, including schizophrenia. Interview on 05/11/22 at 11:11…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, and policy review, the facility failed to ensure residents received medications as physician ordered. This affected two (Residents #25 and #60) of six residents reviewed for medication administration. The facility census was 94. Findings include: 1 Review of the medical record for the Resident #60 revealed an admission date of 02/04/2022. Diagnoses included malignant neoplasm of colon, cerebral infarction, and end stage renal disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of Resident #60's physician orders revealed orders including lorazepam (treats anxiety) 0.5 milligrams (mg) tablet by mouth twice daily. Resident #60 had physician orders for Cefdinir (antibiotic) 300 mg capsule by mouth once daily for a urinary tract infection (UTI) written on 04/23/22 and discontinued on 04/27/22 An order, dated 04/27/22, revealed Resident #60 was to receive ciprofloxacin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure timely physician follow-up to monthly pharmacy recommendations. This affected one (Resident #31) of six residents reviewed for unnecessary medications. The facility census was 94. Findings include: Review of the medical record of Resident #31 revealed an admission date of 02/16/22. Diagnoses included alcohol dependence with alcohol-induced persisting dementia and alcoholic cirrhosis of the liver. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had severely impaired cognition. Review of the Note to Attending Physician/Prescriber dated 03/08/22 revealed the pharmacist recommendations to complete a baseline ammonia level as Resident #31 was taking lactulose and neomycin for hepatic encephalopathy. The Physician/Prescriber response was blank. Review of the medical record for Resident #31 revealed no evidence of a physician response to the recommendations. There was no ammonia level ordered,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and policy review, the facility failed to ensure residents were free from of any significant medication errors. This affected one (Residents #60) of six residents reviewed for medication administration. The facility census was 94. Findings include: Review of the medical record for the Resident #60 revealed an admission date of 02/04/2022. Diagnoses included end stage renal disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of the physician orders revealed Resident #60 had a order for Cefdinir (antibiotic) 300 milligrams (mg) capsule by mouth once daily for a urinary tract infection (UTI) written on 04/23/22 and discontinued on 04/27/22. Resident #60 had an order, dated 04/27/22, to receive ciprofloxacin (antibiotic) 500 mg tablet by mouth twice daily for a UTI. The ciprofloxacin was to end on 05/04/22. Review of the Medication Administration Record (MAR) dated April 2022 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observtions, policy review and staff interview, the facility failed to store medications in a safe manner. This had the potential to affect four (#9, #11, #85 and #90) residents in the 300 to 310 hall, and seven (#3, #8, #34, #47, #52, #53, and #66) residents in the 200 hall identified by the facility as cognitively impaired and independently mobile. The facility census was 92. Findings include: 1) Observation conducted on 05/19/19 at 9:04 A.M., revealed a treatment cart was noted at the intersections of the 200 halls. The cart was observed unlocked, unattended, and contained multiple resident, pharmacy labeled, boxes and tubs of medication creams. Interview on 05/19/19 at 9:05 A.M., with Registered Nurse (RN) #34 verified cart was unlocked and unattended, and should be locked when unattended. 2) Observation on 05/21/19 at 11:13 A.M., during medication cart review of 300 hall, while surveyor was reviewing medication, RN #101 walked away from the cart and into a residents room. Surveyor stepped away from the cart until RN #101 returned. Interview at the time of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy/procedure review and staff interviews, the facility failed to label, and date food items from the walk-in refrigerator. The facility also failed to serve food in a sanitary environment. This had the potential to affect 86 of 86 residents who receive food from the kitchen. The facility identified six residents (#24, #51, #55, #71, #91, and #96) that eat nothing by mouth. Facility census was 92. Findings include: 1. Observation on 05/19/219, between 9:25 A.M. to 9:57 A.M., of the kitchen with [NAME] Supervisor (CS) #25 and Dietary Manager (DM) #41 revealed : a. In the refrigerator there was a container of stew beef sealed with no date or use by date. b. In the refrigerator there was a container of chicken noodle soup sealed with no date or use by date. c. In the refrigerator there was a container of bacon sealed with no date or used by date. d. A half loaf of bread, and three hot dog buns in unsealed/closed bag. e. Garbage cans without lids were in the food preparation areas. f. There were no sanitizing buckets in use to clean food preparation areas.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide Notice of Medicare Non-Coverage (NOMNC) review form for two (#58 and #302) of three residents reviewed for Beneficiary Notices given when discharged from Medicare Part A services. The facility census was 92. Findings include: 1. Review of the medical record for Resident #58 revealed an admission date of 02/28/19. Diagnoses included displaced fracture of the fifth metatarsal bone of the right foot, unsteadiness and muscle weakness. Review of the Skilled Nursing Facility Beneficiary Notification (SNFBN) form revealed Resident #58 was discharged from Medicare Part A on 04/19/19 and did not remain in the facility. Review of the SNFBN form revealed Resident #58 was discharged from Medicare Part A and was not given the NOMNC form. Resident #58 was discharged from the facility on 04/19/19, the day Resident #58 received the SNFBN. There was no explanation as to why the form was not provided. 2. Review of the medical record revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide stop dates for as needed (PRN) psychotropic medications and/or discontinue psychotropic's medications as needed when not administered for more than 14 days. This affected one (#87) of five residents reviewed for unnecessary medications. The facility census was 92. Findings include: Review of the record for Resident #87 revealed an admission date of 07/06/18. Diagnoses included dementia, psychosis, anemia, ischemic heart disease, hypertension, gastro-esophageal reflux disease, hyperlipidemia, cerebral infarction, anxiety, depression, post-traumatic stress disorder, muscle weakness, and lack of coordination. Review of the Quarterly Minimum Data Set, dated [DATE], revealed Resident #87 had severe cognitive deficits, limited assist for locomotion, transfers, extensive assistance with dressing, toileting, and personal hygiene, and occasionally incontinent of bowel and bladder Review of care plan dated 08/20/18, revealed Resident #87 was at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.